The first day of the month in which payroll deductions begin. For life - as long as the required premiums are paid.

Transcription

1 Benefits & Cost Summary: Accident Accident Insurance Accident insurance is designed to help covered employees meet the out-of-pocket expenses and extra bills that can follow an accidental injury, whether minor or catastrophic. Benefit payments may be made for emergency room care, doctor office visits and physical therapy. In major accidents, benefits for catastrophic accident (up to $100,000) and accidental death (up to $25,000) may be payable. The accident base plan is guaranteed issue, so no health questions are required. Coverage effective date: January 1, 2011 Number of eligible employees: 64 Eligibility class descriptions: Class 1: Executives and Management Class 2: All Employees not eligible in another group Plan Description Class 1 Class 2 Type of Plan On/off job On/off job Covered Conditions See Schedule of Benefits See Schedule of Benefits Issue Ages (64 in CA and NY) (64 in CA and NY) Rates Composite Composite Family Coverage Options Employee, Spouse, Child Employee, Spouse, Child Coverage Effective Date Guaranteed Renewable Pre-Existing Condition Period Employer and Employee Elected Options New Employee Waiting Period The first day of the month in which payroll deductions begin For life - as long as the required premiums are paid None for Base 12/12 for Rider Sickness hospital confinement rider 30 Days* The first day of the month in which payroll deductions begin For life - as long as the required premiums are paid None for Base 12/12 for Rider Sickness hospital confinement rider 30 Days* *For new employees who complete their waiting period on or after the plan effective date, coverage will begin on the first of the month following the date they are approved by Unum which is the first of the month payroll deductions begin. *For new employees who complete their waiting period on or after the plan effective date, coverage will begin on the first of the month following the date they are approved by Unum which is the first of the month payroll deductions begin. Minimum Hours for Eligibility 40 hours per week 40 hours per week Minimum number of applications for billing: 2 approved adult applications per product States where enrollment will take place: SC (Actual enrollment states will depend on product availability.) Page 17 of 48

2 Benefits & Cost Summary: Accident Underwriting Guidelines and Limits Accident Guaranteed Issue On/off Job Base Plan Off Job Base Plan Tier I (insured must answer underwriting questions) Sickness Hospital Confinement Rider Accident - Schedule of Benefits Accident Follow-up Treatment Accident Death $50 payable after an insured s initial visit to a doctor s office or emergency room $25,000 - Named Insured $10,000 - Spouse $5,000 - Child Benefit amount doubles if accident occurs on a common carrier. Air Ambulance $500 Ambulance $100 Appliance $100 Blood/Plasma/Platelets $300 Burn $750 - Second degree burns - at least 36% of the body surface $1,500 - Third degree burns - at least 9 but less than 35 square inches of the body surface $10,000-Thirddegreeburns-35ormoresquareinchesofthebody surface. One benefit will be paid per person, per accident Skin Graft Catastrophic Accident If an insured receives the applicable benefit for a burn, we will pay up to 25% of that benefit for a skin graft once per covered accident. Pays a benefit at the end of the 365 day Elimination Period if the insured sustains a catastrophic loss as a result of a covered accident Concussion $100 Prior to age 65 Named insured individual - $100,000 Spouse/Child-$50, Named insured individual - $50,000 Spouse/Child-$25,000 After age 70 Named insured individual - $25,000 Spouse/Child-$12,500 Benefit is payable once per lifetime for each covered person. Dislocation (separated joint) Up to $2,000 - Closed Reduction Up to $4,000 - Open Reduction If reduction is administered without anesthesia, we will pay 25% of the specified dislocation benefit amount. Doctor s Office Emergency Room Treatment $50 initial visit $150 (includes x-ray) Page 18 of 48

3 Benefits & Cost Summary: Accident Accident - Schedule of Benefits Emergency Dental Work $150 Broken teeth repaired with crown(s) $50 Broken teeth resulting in extraction(s) Eye Injury $200 Fractures (broken bones) Hospital Admission Hospital Confinement Hospital Intensive Care Unit Knee Cartilage - Torn Up to $2,500 - Closed Reduction Up to $5,000 - Open Reduction $750 - Benefit payable per admission, per covered person. $200 - Benefit payable for up to 365 days. $400 - Benefit payable for up to 15 days. $500 if repaired through surgery. $100 if exploratory arthroscopic surgery is performed. Laceration $25-$400 Lodging Loss of a Finger, Toe, Hand, Foot, or Sight of an Eye Physical Therapy $100 per night up to 30 days Loss of both hands, both feet, the sight of both eyes, $15,000 or any combination of two or more losses in this list. Loss of one hand, foot or sight of one eye. $7,500 Loss of two or more fingers, two or more toes, or any $1,500 combination of two or more losses in this list. Loss of one finger or toe. $750 $25 per treatment up to 6 per covered accident Prosthetic Device / Artificial Limb $500 One Prosthetic device or artificial limb. $1,000 More than one device or artificial limb. Ruptured Disc $400 Surgery (open abdominal, thoracic) Tendon/Ligament and Rotator Cuff Transportation $1,000 ($100 for exploratory or other surgery without repair) Hernia repair is not covered. Surgical repair of: $400 - One tendon, ligament, or rotator cuff $600 - More than one of the above $100 - Exploratory arthroscopic surgery with no repair $300 up to three trips, if an insured must travel more than 100 miles Schedule of benefits vary in CO, FL, NH and WA. See Policy Definitions for state exceptions. Rates and Cost Information South Carolina Rates. Rates may vary by enrollment state. Premium illustrates base product premium only; optional rider premium is in addition to base premium. Weekly Premium Plan Individual Individual and Spouse One Parent Family Two Parent Family On & Off Job $3.78 $5.40 $7.20 $8.82 Sickness Hospital Confinement Rider $0.81 $1.62 $1.38 $2.19 Page 19 of 48

4 Benefits & Cost Summary: Accident Coverage not available in Connecticut. Vermont applicants must have comprehensive health coverage before applying for specified critical illness coverage. Maximum issue age is 64 for both employee and spouse in California. Underwritten by the following subsidiary of Unum Group: Provident Life and Accident Insurance Company 1 Fountain Square, Chattanooga, TN In New York, coverage is underwritten by: First Unum Life Insurance Company 99 Park Avenue, 6 th Floor, New York, NY Page 20 of 48

5 Benefits & Cost Summary: Specified Critical Specified Critical Insurance Specified critical illness insurance is designed to help employees offset the financial effects of a catastrophic illness with a lump sum benefit (up to $50,000) if an insured individual is diagnosed with the first occurrence of a covered specified critical illness. Covered conditions are heart attack, stroke, major organ transplant, permanent paralysis, end-stage renal (kidney) failure and the need for coronary artery bypass surgery. Coverage effective date: January 1, 2011 Number of eligible employees: 64 Eligibility class descriptions: Class 1: Executives and Management Class 2: All Employees not eligible in another group Plan Description Class 1 Class 2 Type of Plan Enhanced Plan Enhanced Plan Covered Conditions Base Plan: Heart attack, stroke, major organ transplant, permanent paralysis, kidney failure, coronary artery bypass surgery Enhanced Plan: Same covered conditions as base plan plus cancer and carcinoma in situ Base Plan: Heart attack, stroke, major organ transplant, permanent paralysis, kidney failure, coronary artery bypass surgery Enhanced Plan: Same covered conditions as base plan plus cancer and carcinoma in situ Maximum Benefit Amount Employee - $50,000 Spouse - $30,000 Child - $10,000 Minimum Benefit Amount Employee - $5,000 Spouse - $5,000 Child - $5,000 Employee - $50,000 Spouse - $30,000 Child - $10,000 Employee - $5,000 Spouse - $5,000 Child - $5,000 Employee and Spouse Benefit Increments $1,000 $1,000 Issue Ages (64 in CA) (64 in CA) Rates Age last birthday, unisex, tobacco distinct Age last birthday, unisex, tobacco distinct Family Coverage Options Employee, Spouse, Child Employee, Spouse, Child Coverage Effective Date The first day of the month in which payroll deductions begin The first day of the month in which payroll deductions begin Benefit Reduction Age 70 Age 70 Guaranteed Renewable For life - as long as the required premiums are paid For life - as long as the required premiums are paid Pre-Existing Condition Period 12/12 12/12 Employer Elected Options Health screening benefit rider Health screening benefit rider Employer and Employee Elected Options Employee Elected Options Spouse rider Child rider Base Plan Enhanced Plan Spouse rider Child rider Base Plan Enhanced Plan Page 21 of 48

6 Benefits & Cost Summary: Specified Critical Plan Description Class 1 Class 2 New Employee Waiting Period 30 Days* *For new employees who complete their waiting period on or after the plan effective date, coverage will begin on the first of the month following the date they are approved by Unum which is the first of the month payroll deductions begin. 30 Days* *For new employees who complete their waiting period on or after the plan effective date, coverage will begin on the first of the month following the date they are approved by Unum which is the first of the month payroll deductions begin. Minimum Hours for Eligibility 40 hours per week 40 hours per week Participation required for conditional guarantee issue for employee: Greater of 100 employee applications or 20% Minimum number of applications for billing: 2 approved adult applications per product States where enrollment will take place: SC (Actual enrollment states will depend on product availability.) Underwriting Guidelines and Limits Tier I (insured must answer underwriting questions) Specified critical illness Employee - $5,000 to $30,000 Spouse - $5,000 to $30,000 *Child(ren) - $10,000 Tier II (insured must answer additional underwriting questions) Employee-$31,000-$50,000 Spouse - N/A Child(ren)-N/A With the greater of 100 employee applications or 20% participation, CGI is available for up to $10,000 for Employee. * Child(ren) - $5,000 is Guaranteed Issue Rates and Cost Information South Carolina Rates. Rates may vary by enrollment state. Premium illustrates base product premium only; optional rider premium is in addition to base premium. Employee Weekly Premiums Based on $10,000 Benefit Amount* Age Base Critical Base Critical $0.70 $1.30 $1.04 $ $1.04 $2.06 $1.83 $ $2.13 $4.04 $3.97 $ $3.74 $7.48 $7.30 $ $6.03 $11.63 $11.20 $21.58 Page 22 of 48

7 Benefits & Cost Summary: Specified Critical Employee Weekly Premiums Based on $20,000 Benefit Amount* Age Base Critical Base Critical $1.39 $2.59 $2.08 $ $2.08 $4.11 $3.65 $ $4.25 $8.08 $7.94 $ $7.48 $14.96 $14.59 $ $12.05 $23.27 $22.39 $43.16 Employee Weekly Premiums Based on $30,000 Benefit Amount* Age Base Critical Base Critical $2.08 $3.88 $3.12 $ $3.12 $6.17 $5.47 $ $6.37 $12.12 $11.91 $ $11.22 $22.43 $21.88 $ $18.07 $34.90 $33.58 $64.73 Employee Weekly Premiums Based on $40,000 Benefit Amount* Age Base Critical Base Critical $2.77 $5.17 $4.16 $ $4.16 $8.22 $7.30 $ $8.50 $16.16 $15.88 $ $14.96 $29.91 $29.17 $ $24.10 $46.53 $44.77 $86.31 Page 23 of 48

8 Benefits & Cost Summary: Specified Critical Employee Weekly Premiums Based on $50,000 Benefit Amount* Age Base Critical Base Critical $3.47 $6.47 $5.20 $ $5.20 $10.27 $9.12 $ $10.62 $20.20 $19.85 $ $18.70 $37.39 $36.47 $ $30.12 $58.16 $55.97 $ *Same rates apply for the Spouse rider. Child Rider Weekly Premiums for $5,000 Benefit Amount Age Base Critical 14 days - 24 years $0.10 $0.30 Child Rider Weekly Premiums for $10,000 Benefit Amount Age Base Critical 14 days - 24 years $0.19 $0.60 Health Screening Benefit Rider Weekly Premium Employee policy $0.47 Spouse rider $0.47 Child rider $0.47 Coverage not available in Connecticut, Massachusetts, Minnesota, New Jersey, New York, Virginia and Washington. Eligibility for, entitlement to, and amount of actual benefits will be determined according to the terms of the voluntary individual specified critical illness insurance policy. Coverage amounts and rates may vary by state. The spouse benefit amount maximum is $30,000. Spouse coverage is issued up to age 64 for all states. Maximum issue age is 64 for both employee and spouse in California. Georgia - Permanent paralysis is not covered specified critical illness. California, Delaware, Georgia, Maine, Oregon, Pennsylvania, Texas and Vermont applicants must have comprehensive health coverage before applying for specified critical illness coverage. In Pennsylvania, coverage is not allowed if applicant has specified disease/cancer coverage. The maximum issue amount for primary insured / employee coverage in Maryland is $50,000. The health screening benefit rider provides a $50 benefit per calendar year per covered person(s). Once the health screening benefit rider is chosen by the employer, all insureds covered by a critical illness policy or critical illness rider will automatically receive this benefit. The additional specified critical illness benefit provides an additional lump-sum benefit if diagnosed with cancer and/or carcinoma in situ. Page 24 of 48

9 Benefits & Cost Summary: Specified Critical Underwritten by the following subsidiary of Unum Group: Provident Life and Accident Insurance Company 1 Fountain Square, Chattanooga, TN THIS IS A LIMITED POLICY. Page 25 of 48